Countries were requested to follow the 2012 EU hepatitis C case definition for ... box next page), but data were still a
SURVEILLANCE REPORT
Hepatitis C surveillance in Europe 2013 Hepatitis C virus infection Key facts • • • •
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In 2013, 31 513 cases of hepatitis C were reported in 26 EU/ EEA Member States, a crude rate of 9.6 per 100 000 population. Of cases reported in 2013, 569 (1.8%) were reported as ‘acute’, 4 776 (15.2%) as ‘chronic’, 23 230 (73.7%) as ‘unknown’ and 2 938 cases (9.3 %) were not classified due to incompatible data formats. The male-to-female ratio was 1.9 to 1. The most affected age group were those between 25 and 34 years of age (29.3 cases per 100 000 in males, 15.1 cases per 100 000 in females). The most common route of transmission reported across all disease categories was injecting drug use, which accounted for 80.7% of all cases with complete information. Nosocomial transmission is an uncommon route of transmission in most countries, but remains a commonly reported transmission route in a small number of countries. The interpretation of hepatitis C data across countries is hampered by differences in surveillance systems and difficulties in defining the cases as acute or chronic. In addition, surveillance of hepatitis C, which is largely asymptomatic until a late stage, is challenging, with reported notifications reflecting testing practices rather than true occurrence of disease.
Methods This summary includes data on newly diagnosed cases of hepatitis C reported to ECDC by EU/EEA countries for 2013. Countries were requested to follow the 2012 EU hepatitis C case definition for reporting at the European level 1 (see text box next page), but data were still accepted if other case definitions were used. 1
2012/506/EC: Commission Implementing Decision of 8 August 2012 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council
Suggested citation: European Centre for Disease Prevention and Control. Hepatitis C surveillance in Europe – 2013. Stockholm: ECDC; 2015. Stockholm, July 2015 ISBN 978-92-9193-661-8 doi 10.2900/930794 Catalogue number TQ-04-15-522-EN-N © European Centre for Disease Prevention and Control, 2015 Reproduction is authorised, provided the source is acknowledged.
ECDC SURVEILLANCE REPORT
Hepatitis C surveillance in Europe, 2013
2012 EU case definition for hepatitis C Clinical criteria: not relevant for surveillance purposes Laboratory criteria: At least one of the following three:
Detection of hepatitis C virus nucleic acid (HCV RNA) Detection of hepatitis C virus specific antigen (HCV core) Hepatitis C virus specific antibody (anti-HCV) response confirmed by a confirmatory (e.g. immunoblot) antibody test in persons older than 18 months without evidence of resolved infection
Epidemiological criteria: Not relevant for surveillance purposes Case classification: Possible case – N/A Probable case – N/A Confirmed case – Any person meeting the laboratory criteria Note: The following combination of laboratory tests shall not be included or reported: Resolved infection: Detection of hepatitis C virus antibody and no detection of hepatitis C virus nucleic acid (HCV RNA negative result) or hepatitis C virus core antigen (HCV‐core negative result) in serum/plasma.
Acute and chronic hepatitis C infections were distinguished using the following criteria (Table 1). Table 1. Criteria for differentiating acute and chronic hepatitis C Stage Acute
Definition Recent HCV seroconversion (prior negative test for hepatitis C in last 12 months)
or Detection of hepatitis C virus nucleic acid (HCV RNA) or hepatitis C virus core antigen (HCV-core) in serum/plasma and no detection of hepatitis C virus antibody (negative result) Chronic
Detection of hepatitis C virus nucleic acid (HCV RNA) or hepatitis C core antigen (HCV-core) in serum/plasma in two samples taken at least 12 months apart*
Unknown
Any newly diagnosed case which cannot be classified in accordance with the above definition of acute or chronic infection
* In the event that the case was not notified the first time.
Data are collected annually in a case-based format, but if case-based data are not available, aggregate format is accepted. Surveillance systems across the EU/EEA countries are heterogeneous (Annex). Fourteen countries were able to provide national data for 2013 in accordance with the current EU case definition (EU 2012), seven countries used the previous EU case definition (EU 2008), and five countries provided data as specified by their national case definitions. The EU 2012 case definition is similar to the one from 2008 but adds a diagnostic criterion (detection of hepatitis C virus core antigen). Both case definitions capture all laboratory-diagnosed cases of hepatitis C, irrespective of stage. In a small number of countries, the case definitions changed between 2006 and 2012, as countries adapted to the new case definition. Seventeen countries were able to classify cases as ‘acute’ or ‘chronic’. A few countries use non-EU case definitions, and submitted cases classified as ‘unknown’ or ‘probable’. France and Liechtenstein do not provide any hepatitis C data. All reported cases were included in the analysis, regardless of which case definition was used to classify the cases. Before analysis, data were validated with appointed data providers in Member States. For countries with comprehensive surveillance systems covering the entire population, annual notification rates were calculated per 100 000 population, based on the denominator data published by Eurostat2.
Epidemiology In 2013, 31 513 cases of hepatitis C virus (HCV) infection were reported in 26 EU and EEA Member States (no national data from Belgium, France, Italy, Liechtenstein and Spain) with a crude rate of 9.6 per 100 000 population (Annex 1). Of these cases, 569 (1.8%) were reported as ‘acute’, 4 776 (15.2%) as ‘chronic’, 23 230 (73.7%) as ‘unknown’, and 2 938 cases (9.3%) were not classified by disease status due to an incompatible data format.
2
Eurostat database. Available from: http://epp.eurostat.ec.europa.eu
2
ECDC SURVEILLANCE REPORT
Hepatitis C surveillance in Europe, 2013
In 2013, the number of cases reported ranged from 14 in Malta (3.3 cases per 100 000) to 13 757 (21.5 cases per 100 000) in the United Kingdom. Between 2006 and 2013, the overall number of reported cases increased by 18.9%, but the overall rate per 100 000 population fluctuated very little over these eight years (Figure 1). Figure 1. Rate of reported hepatitis C cases per 100 000 population in EU/EEA countries, by year, 2006– 2013 12
Cases per 100 000
10 8 6 4 2 0 2006
2007
2008
2009
2010
2011
2012
2013
Note: All cases are included: cases (acute, chronic, unknown) Source: Country reports from Austria, Belgium, Bulgaria, Croatia, Cyprus, the Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom.
Figure 2 shows the notification rate of hepatitis C cases in EU/EEA countries. Countries were included if their surveillance system was known to capture data on both acute and chronic cases, even if most of the cases were classified as ‘unknown’. Despite the limitations of this approach, it helps to visualise the higher rates of reporting of cases in central and north European countries and the lower rates in south-east European countries. Figure 2. Rate of reported hepatitis C cases per 100 000 population in 22 EU/EEA countries, 2013
Source: Country reports from Austria, Bulgaria, Croatia, Cyprus, the Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Iceland, Ireland, Latvia, Luxembourg, Norway, Poland, Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom.
Hepatitis C is more commonly reported among men than women, with a rate ratio of 1.9 to 1. Just over half (53.5%) of all hepatitis C cases reported in 2013 were aged between 25 and 44 years, and 8.6% of cases were under 25 years of
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ECDC SURVEILLANCE REPORT
Hepatitis C surveillance in Europe, 2013
age (Figure 3). The notification rate for both males and females was highest in the 25 to 34 age group (29.3 cases per 100 000 in males and 15.1 in females). Data regarding the most likely mode of transmission of hepatitis C were complete for 8 226 (25.3%) cases in 2013. Overall, the most commonly reported route of transmission was injecting drug use, accounting for 80.7% of all cases with a known transmission route in 2013. The percentage of injecting drug use among cases with a known transmission route was lower among acute cases (39.3%) than among those classified as chronic (77.6%) or ‘unknown’ (85.5%). Among acute cases, main routes of transmission included nosocomial transmission (23.5%) and transmission among men who have sex with men (14.0%). Among cases attributed to nosocomial transmission, 82.1% were reported by just four countries (Italy, Latvia, Romania and Slovakia). In 2013, 19 countries provided data for a total of 12 470 cases (38.4%) on whether a case was considered to have been ‘imported’ from outside the reporting country or acquired in the country itself. Of those cases, 1 097 (8.8%) were eventually reported as being imported. Figure 3. Rate of all reported hepatitis C cases per 100 000 by age group and gender, EU/EEA countries, 2013 35
Male Female
Cases per 100 000
30 25 20 15 10 5 0
